Case Study Video Assignment #3: Maggie Smith- Sore Throat
Students Names ________R________________________________________________________
Case Study Video Assignment #3
Maggie Smith- Sore Throat
Students will watch the video and fill in the blanks on the documentation.
- Complete the SOAP Note. (We have given the history on this note).
- Describe 3 of the highest possible differential diagnosis. Rule-in and Rule-out each diagnosis. Example: If a patient presents with a painful knee and your top differentials are osteoarthritis, ACL, and Fracture, you would find Evidence to prove that each of those are possible diagnosis. For osteoarthritis: Rule in: What signs and symptoms match what the patient has. Give the evidence (from peer reviewed based information) to show that the symptoms match. Then rule out: What is lacking to show this is the actual diagnosis? You must prove your thoughts with peer reviewed information
- Complete the Illness script for 3 differential diagnosis.
SUBJECTIVE:
CC
HPI – 19-year-old established patient accompanied by her roommate for complaint of abdominal pain that is increasing in pain.
- Onset –
- Location-
- Duration –
- Character –
- Aggravating factors –
- Alleviating factors –
- Timing –
- Severity –
PMH – A hx of dysmenorrhea. Treated with ortho-cyclin since age 15 years which has been effective for tx of dysmenorrhea. Patient ran out of ortho-cyclin 2 months ago and has not follow-up for a prescription refill.
Medications – Past – Ortho-cyclen. Occasional Tylenol for headache, fever, discomfort…
Mother- 45 years Hx of HTN, and hyperlipidemia. Hysterectomy at age 30 due to ovarian cancer.
Father – 45 years Hx of DM II
Sister – age 28 – healthy
Brother – age 25 – diagnosed with bipolar disease dx at age 18 years.
MGM – Deceased at age 60 – breast cancer, hx of HTN
MGF – 65 years, Alive, HTN, Hyperlipidemia
PGM – History not known
PGF – History not known
PSH-Appendectomy 1 year ago, no hospitalizations, Vaginal delivery with no complications
Social hx: Attending TTU for elementary education. Active in her church.
G0, P0 Last menstrual cycle 1 month ago. Is sexually active with 2 partners. Uses a condom most of the time. Admits to oral and vaginal intercourse.
ROS:
OBJECTIVE DATA
Assessment
Plan: What tests will you run (give rationale)
| Illness Scrip | Differentiate #1 |
| Epidemiology | |
| Time Course | |
| Clinical Presentation | |
| Pathophysiology | |
| Lab | |
| Imaging |
| Illness Scrip | Differentiate #2 |
| Epidemiology | |
| Time Course | |
| Clinical Presentation | |
| Pathophysiology | |
| Lab | |
| Imaging |
| Illness Scrip | Differentiate #3 |
| Epidemiology | |
| Time Course | |
| Clinical Presentation | |
| Pathophysiology | |
| Lab | |
| Imaging |
Maggie Smith Case #2 & #3
| Maggie Smith Case #2 & #3 | |||||
| Criteria | Ratings | Pts | |||
| This criterion is linked to a Learning OutcomeSubjective
Includes Appropriate CC, History of Present Illness, Personal and Family History, medications, Allergies, and ROS. Includes VS and Exam description. Written appropriately for a SOAP Note |
|
35.0 pts | |||
| This criterion is linked to a Learning OutcomeObjective information
Includes VS and Exam description. Written appropriately for a SOAP Note |
|
35.0 pts | |||
| This criterion is linked to a Learning OutcomeAssessment
The Assessment is written with correct terminology for this case |
|
10.0 pts | |||
| This criterion is linked to a Learning OutcomePlan
The Plan for a comprehensive exam should include any follow-up for this patient. Include any future plans for exams, diagnostics, ect…. that might be appropriate. |
|
10.0 pts | |||
| This criterion is linked to a Learning OutcomeIllness Script
Complete the illness script for 3 priority differentials. Answers should be short, including only pertinent information. |
|
5.0 pts | |||
| This criterion is linked to a Learning OutcomeScholarly Writing
Writing is written at the graduate level with no spelling errors. Citations and the reference page are written correctly. |
|
5.0 pts | |||
| Total Points: 100.0 | |||||